Woolworths
Travel Insurance
Personal Accident, Personal Liability and Legal Expenses Claim Form
When completing this form you need to be honest and tell us anything that you or a reasonable person in your
circumstances would be expected to know or we may reduce or refuse to pay a claim or cancel the policy if you
have not answered our questions in this way. By completing this form you confirm that you understand your Duty of
Disclosure. In addition, you confirm you have read our Privacy Policy available online at woolworths.com.au/insurance
Please mail your completed claim form and required documents to Woolworths Travel Insurance Claims,
PO Box 4860, Sydney, NSW 2001 or fax to +61 2 9299 8694
Claimant Details
Claim Reference (if known)
Title (Mr/Mrs etc):
Surname:
Forename(s):
Nationality:
Medicare
Number:
Occupation:
Date of Birth:
/
/
Parent/Guardian’s Medicare Number:
(If medical claim for a minor)
Home Address:
Suburb:
Phone: (home)
State
(
)
(work) (
)
Postcode
(mobile)
Email:
Policy details
Policy Number:
Date Issued:
Independent Travel Arrangements:
Yes
/
/
No. in Party:
No (If no, provide the following *):
* Travel Agent & Branch:
* Tour Operator:
Date of Booking:
/
Country:
/
Departure Date:
/
/
/
Return Date:
/
Total Days:
Resort/Town:
It is against the law to submit a fraudulent insurance claim. If your claim is found to be fraudulent the claim will be declined and Insurers will
pursue recovery by the use of civil action.
1. I/We hereby declare that all information, answers, and documents given in connection with this claim are true and correct to the best of my/our knowledge
and belief. I/We have not omitted any material information, which would affect the Underwriters judgment of the claim. I confirm that where a claim or claims
are made on behalf of others, I have their full authority to act on their behalf, and I confirm that I understand that neither Woolworths Travel Insurance nor the
underwriters will accept responsibility if any payments are not distributed proportionately to the persons concerned.
2. I/We understand that the information on this form will be passed to or used by Woolworths Travel Insurance for my insurance, this includes underwriting,
processing, handling claims and preventing fraud and could include passing details to agents or other Insurers.
3. I/We subrogate all rights of recovery to Woolworths Travel Insurance and also consent to them seeking reimbursement of any medical expenses paid by them.
For medical related claims:
4. I authorise any doctor, hospital or other organisation or person having any records or information concerning my medical history or treatment to furnish such
records or information as may be requested by Woolworths Travel Insurance or their agents. I understand that in executing this authorisation, I waive the right
for such information/records to be privileged. I am also aware that such information/records are relevant in the evaluation of my claim and that non-submission
could prejudice my claim. A photocopy of this authorisation shall be considered as effective and valid as the original.
I have read and fully understand the declarations above (ALL persons claiming must sign)
Claimants Name
Signature
Date of Birth
/
/
Date
/
/
Date of Birth
/
/
Date
/
/
Claimants Name
Signature
Continue with the questions on the next page…
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Documents You Need to Send Us – SEND ORIGINAL DOCUMENTS BUT KEEP COPIES FOR YOUR RECORDS
Personal Accident Claims
1.Original evidence to show your dates of outward and return travel, eg booking invoice, travel tickets, itinerary etc.
2.Send us a full account of the circumstances leading to the accident and the injuries sustained, including details of any witnesses or third parties involved in
the incident.
3.Please provide the details of your regular general practitioner and any specialists from whom you have received treatment and your written confirmation
that we may contact them for further information.
Personal Liability Claims
1. Original evidence to show your dates of outward and return travel, eg booking invoice, travel tickets, itinerary etc.
2. Send us ALL correspondence received from any third party – THIS MUST BE UNANSWERED.
3.Provide a fully detailed account of the incident below, including damage, injuries and names and addresses of any witnesses or third parties involved.
(Continue on a separate sheet if necessary.)
Special Note: Do not under ANY circumstances talk or write to any person regarding the incident, as this WILL invalidate your claim.
Legal Expenses Claims
1. Original evidence to show your dates of outward and return travel, eg booking invoice, travel tickets, itinerary etc.
2.Provide a fully detailed account of the incident below, including damage, injuries and names and addresses of any witnesses or third parties involved.
(Continue on a separate sheet if necessary.)
3.Please provide details of your registered medical practitioner and any specialists from whom you have received treatment, together with your written
consent to contact them for further information.
4. Send us ALL correspondence received from any third party – THIS MUST BE UNANSWERED.
Special Note: Do not under ANY circumstances talk or write to any person regarding the incident, as this WILL invalidate your claim.
Personal Accident, Personal Liability and Legal Expenses
Type of claim:
Personal Accident
Personal Liability
Legal Expenses
Send to Woolworths Travel Insurance Claims, PO Box 4860, Sydney, NSW 2001 or fax to +61 2 9299 8694
National phone: 1300 10 1234
Emergency:
+61 2 9333 3903
International phone: +61 2 9333 3904
Email: [email protected]
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Third Party Contact Details
Other Insurance
Do you (or anyone else claiming) have any other insurance which may cover this trip (e.g. travel
insurance with your bank/credit card account, tour operator/travel agent or home contents insurance etc):
Yes
No
Yes
No
NB (a contribution payment is normal practice where 2 policies cover the same loss)
If yes, please supply the following details:
Company name
and address:
Has a claim been submitted to any
other company for this incident:
Policy No:
Please provide details:
Method of payment for the trip:
Cash
Cheque
Credit/Debt Card
Reward points/Airmiles
If a Credit/ Debt card was used to pay all or some of the trip cost, please state:
Name of card supplier
Card type
Previous Claims
Have you made any previous claims on this type of insurance:
Yes
No
If yes, please provide details:
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